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ALS Recertification Course
• Standardised CPR for adults
• Update on clinical changes to resuscitation guidelines
• Re-evaluation of knowledge and practical skills acquisition
• Assessment
ALS recertification course learning outcomes
ALS recertification course format
• Manual
• Lectures
• Skill stations
• Cardiac Arrest Simulation (CAS) training
ALS recertification course assessment
• MCQ
• Practical skills (continuous assessment)• Airway management• Initial assessment and resuscitation
• Cardiac Arrest Simulation (CASTest)
• Provider certificate valid for 4 years
Causes and Prevention of Cardiac Arrest
Early recognition ofthe deteriorating patient
• Most arrests are predictable
• Deterioration prior to 50 - 80% of cardiac arrests
• Hypoxia and hypotension are common antecedents
• Delays in referral to higher levels of care
Outcome after in-hospital cardiac arrest
VF/VT Non-VF/VT
Number of patients 570 (18%) 2,614 (82%)
ROSC > 20 min 385 (68%) 689 (26%)
Survival to hospital discharge 251 (44%) 179 (7%)
Source: UK National Cardiac Arrest Audit (NCAA) 2010
•No national data for Australia
•Pockets of data report similar results
•Development of Clinical Indicators/Audits by Australian Council on Healthcare Standards (ACHS) and Australian Commission on Safety and Quality in Health Care (ACSQHC) will provide future results
Recognition of the deteriorating patient -Early Warning Scoring Systems
Example of early warning scoring (EWS) system** From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7
Recognition of the deteriorating patient -Early Warning Scoring Systems
Example Escalation Protocol based on early warning score (EWS)
The ABCDE approach to the deteriorating patient
Airway
Breathing
Circulation
Disability
Exposure
ALS Algorithm
• Patient response
• Open airway
• Check for normal breathing• Caution agonal breathing
• Check circulation
• Monitoring
To confirm cardiac arrest…Unresponsive?Not breathing or
only occasional gasps
Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
CPR 30:2Attach defibrillator / monitor
Minimise interruptions
Chest compression• 30:2• Compressions
• Centre of chest• Min 5cm depth/one third total• Approximately 100min-1
- About 2 per second (not faster than 120 min-1)
• Maintain high quality compressions with minimal interruptions
• Continuous compressions once airway secured
• Switch CPR provider every 2 min cycle to avoid fatigue
Adult ALS Algorithm
Shockable and Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Charge START Defibrillator
Assessrhythm
Shockable(VF / Pulseless VT)
Non-Shockable(PEA / Asystole)
CPR
• Uncoordinated electrical activity
• Coarse/fine• Exclude artefact
• Movement• Electrical interference
Shockable (VF)Shockable(VF)
• Bizarre irregular waveform• No recognisable QRS
complexes• Random frequency and
amplitude
Shockable (VT)Shockable(VT)
• Polymorphic VT• Torsade de pointes
• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology
Shockable (VF / VT)
Shout “(Compressions Continue) Stand Clear”
Assessrhythm
Shockable(VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Shockable (VT)
CHARGE DEFIBRILLATOR
Assessrhythm
Shockable(VF / VT)
Shockable (VT)
Assessrhythm
Shockable(VF / VT)
Shout “Hands Off”
CHARGE DEFIBRILLATOR
Shockable (VF / VT)
Assessrhythm
Shockable(VF / VT)
Confirmed Hands Off“I’m Safe”
Shockable (VF / VT)
DELIVER SHOCK
Assessrhythm
Shockable(VF / VT)
Shockable (VF / VT)
IMMEDIATELY RESTART CPR
Assessrhythm
Shockable(VF / VT)
Shockable (VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assessrhythm
Shockable(VF / VT)
IMMEDIATELY RESTART CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
• Vary with manufacturer
• Check local equipment• Defibrillator energy 200 Joules
• unless manufacturer demonstrates better outcomes with alternate energy level
• If unsure, deliver 200 Joules• DO NOT DELAY SHOCK
• Energy levels for defibrillators on this course…
Defibrillation energies
Special Circumstances
Well perfused and oxygenated patient pre-arrestPresenting arrest shockable
• Three stacked shocks•First shock delivered within 20 seconds of onset of arrest
• Precordial thump•Pulseless VT only•Defibrillator unavailable •Delivered within 20 seconds of onset of arrest
• 2nd and subsequent shocks• 200 J biphasic• 360 J monophasic
• Give adrenaline and after 2nd shock during CPR then alternate loops thereafter
• Give amiodarone after 3rd shock during CPR
If VF / VT persists
CPR for 2 minDuring CPR
Adrenaline 1 mg IV
CPR for 2 minDuring CPR
Amiodarone 300 mg IV
Deliver 2nd shock
Deliver 3rd shock
Non-Shockable
Assessrhythm
Shockable(VF / Pulseless VT)
Non-Shockable(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Non-Shockable
Assessrhythm
Shockable(VF / Pulseless VT)
Non-Shockable(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
DUMP/DISCHARGE
ENERGY
• Absent ventricular (QRS) activity• Atrial activity (P waves) may persist• Rarely a straight line trace
• Adrenaline 1 mg IV then every alternate loop
Non-shockable (Asystole)Non-Shockable(Asystole)
• Clinical features of cardiac arrest• ECG normally associated with an output• Adrenaline 1 mg IV then every alternate loop
Non-shockable (Asystole)Non-Shockable(PEA)
During CPRDuring CPR
Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO accessPlan actions before interrupting compressions
(e.g. charge manual defibrillator)Drugs
Shockable• Adrenaline 1 mg after 2ndshock (then every 2nd loop)• Amiodarone 300 mg after 3rd shock Non Shockable• Adrenaline 1 mg immediately (then every 2nd loop)
Airway and ventilation
• Secure airway:• Supraglottic airway device • Tracheal tube
• Do not attempt intubation unless trained and competent to do so
• Once airway secured, if possible, do not interrupt chest compressions for ventilation
• Avoid hyperventilation
• Waveform capnography
Vascular access
• Peripheral versus central veins
• Intraosseous
Reversible causesHyperthermia
Hypokalaemia/metabolic
Hypoxia
• Ensure patent airway
• Give high-flow supplemental oxygen
• Avoid hyperventilation
Hypovolaemia
• Seek evidence of hypovolaemia• History• Examination
- Internal haemorrhage- External haemorrhage- Check surgical drains
• Control haemorrhage
• If hypovolaemia suspected give intravenous fluids
Hypo/hyperkalaemia and metabolic disorders
• Near patient testing for K+ and glucose
• Check latest laboratory results
• Hyperkalaemia• Calcium chloride• Insulin/dextrose
• Hypokalaemia/ Hypomagnesaemia• Electrolyte
supplementation
Hypothermia
• Rare if patient is an in-patient
• Use low reading thermometer
• Treat with active rewarming techniques
• Consider cardiopulmonary bypass
Hyperthermia• Heat stroke can
resemble septic shock
• Core temp >40.6 C
• Rhabdomyolysis, coagulopathy issues
• Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm
• Rapid cooling to 39 C (similar approaches/techniques to hypothermia)
• Large fluid volumes• Correct electrolyte
abnormalities/acidosis
Medications:• No effective medications for heat
stroke• Dantrolene for some
anaesthetic/MDMA reactions
Tension pneumothorax
• Check tube position if intubated
• Clinical signs (some/all not be present peri-arrest)
• Decreased breath sounds• Hyper-resonant percussion note• Tracheal deviation
• Initial treatment with needle decompression or thoracostomy• Follow up with Chest Tube
Tamponade, cardiac
• Difficult to diagnose without echocardiography
• Consider if penetrating chest trauma or after cardiac surgery• Also:
- Recent Myocardial Infarct- Blunt Chest Trauma- Procedural – Cardiac
Catheter/Pacing Wire etc• Treat with needle
pericardiocentesis or resuscitative thoracotomy
Toxins
• Rare unless evidence of deliberate overdose
• Presenting history may give clues
• Review drug chart
• Toxicology screens take time
Thrombosis
• If high clinical probability for PE consider fibrinolytic therapy
• If fibrinolytic therapy given then consideration for continuing CPR for up to 60-90 min before halting resuscitation attempts
Ultrasound
• In skilled hands may identify reversible causes
• In particular Tamponade, Tension Pneumothorax and Thrombosis
• Obtain images during rhythm checks
• Do not interrupt CPR
Immediate post-cardiac arrest treatment
Resuscitation team
• Roles planned in advance• Identify team leader• Importance of non-technical skills
• Task management• Team working• Situational awareness• Decision making
• Structured communication
Any questions?
• The ALS algorithm
• Importance of high quality chest compressions
• Treatment of shockable and non-shockable rhythms
• Administration of drugs during cardiac arrest
• Potentially reversible causes of cardiac arrest
• Role of resuscitation team
Summary
Peri-Arrest
Bradycardia algorithmIncludes rates inappropriately slow for haemodynamic state
Interim measures:
•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing
Tachycardia algorithm (with pulse)
Tachycardia algorithm
Stable broad-complex tachycardia
Stable narrow-complex tachycardia
Any questions?
Summary
• Modifications to ALS are based upon current evidence
• Focus is on standardised CPR for adults
Advanced Life Support Recertification Course
Slide setAll rights reserved
© Australian Resuscitation Council and Resuscitation Council (UK) 2010